The forms an investigation takes
Healthcare fraud investigations come from the HHS Office of Inspector General, the Justice Department, Medicare contractors, private insurers, and in New York, the Office of the Medicaid Inspector General and the Attorney General's Medicaid Fraud Control Unit. An audit letter or records request usually signals a billing review; a civil investigative demand points to a False Claims Act inquiry; a grand jury subpoena or search warrant points to a criminal one. Civil cases are often started by a whistleblower filing under seal, so an investigation can be underway long before the practice learns of it. Matters can also move from one track to another, which is why the first response should assume the stakes may grow.
If agents arrive at the practice
Ask for a copy of the warrant, call counsel, and let the agents carry out the search without interference. Staff can be told, accurately, that they may choose whether to speak with agents and may ask to have a lawyer present, but no one should discourage them from cooperating or suggest what to say. Keep track of what is taken, and ask how patient care records needed for ongoing treatment can be copied. Do not delete, alter, or add to any records afterward, including notes meant to complete a chart. Employees may need their own counsel, separate from the practice's.
Keeping the practice running
A payment suspension can threaten cash flow quickly, and there are processes for challenging or narrowing it that should be started early. If the review identifies overpayments, repayment obligations can arise on their own timeline, and holding a known overpayment can create separate liability. Licensing boards, exclusion from federal programs, and private payer contracts are related risks that need watching. A privileged internal review, done through counsel, helps the practice understand its exposure before responding in substance. A first consultation identifies which agency is driving the matter and plans the immediate response, including what staff should do when agents call.
